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tv   Heroin and Prescription Drug Abuse  CSPAN  October 28, 2014 8:38pm-10:28pm EDT

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>> come to order, i would like to welcome our distinguished witnesses, and they will be introduced shortly. recent recently, the media has chronicles a resurgence of heroin abuse in the united states and actually more heroin being moved into the country. according to a 2012 national survey, 666,000 americans reported using heroin during the previous year. that number has steadily grown over the past several years. so this begs the question why are more people using heroin and this is the senate caucus on
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international drug control, but the reason to control it is to keep it out of our country and to do those things which prevent opiate use, not to enable it, but one answer according to the experts may be the country's addiction and use of prescription pain medications, a report released by the substance abuse and mental health services that people who use prescript n prescription -- that's an amazing thing to me. furthermore, four out of every five heroin abusers -- in much
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the same way as heroin, the lesson here is that rather than thinking of two separate addictions, prescription pain medications, and heroin, we should realize that we're facing a much larger opiate addiction epidemic that includes both, so the strategy to -- treat the number of overdoses, but the first and most important strategy is to prevent drug abuse before it starts and this means educating communities and youths about the dangers. now some communities already do this through the federal drug free communities program --
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prescribed and dispensed only for legitimate medical purposes. state based prescription drug monitoring programs, along with mandatory checks of electronic databases can help doctors and pharmacists identify drug abusers. since requiring mandatory checks, new york has seen a 75% decrease in doctor shopping and significant reduction and pain reliever prescription so drug take back programs can also help
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redu reduce opiod abuse, to get them out of medicine cabinets where young people obtain these drugs. the dea's heroin signature program in 2012, determined that 90% of wholesale heroin seizures were able to be traced from mexico or south america, dea also reports that the mexican based drug cartel is expanding its market eastward and producing and selling heroin and it's more pure, it's in the brown or the white heroin, between 2008 and 2013, heroin seizures along the southwest border increased nearly four fold. from 559 kilograms, to 2196.
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the second key strategy in this fight is successful treatment, which often includes medication assisted therapies using drugs like methadone and i'm going to have trouble with this one, bupenorphine. thank you, sirs. unfortunately, in 2012, 2.5 million people in our country were addicted to these opiods, where only 351 ,000 received these methadons or these bupenorphine to treat their addictions, that means the rest aren't receiving treatment. finally the third strategy is to release overdose deaths, in 2010, the latest year for which data is available, the centers for disease control and
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prevention reported more than 19,500 unintentional opiod overdose deaths. there's steps that can be taken, there are drugs that immediately reverse these overdoses, and 18 states including california have taken actions to improve access to these drugs, i think we need to find a way to make these drugs more available to properly administer to individuals, including first responders. i think we have an interesting hearing, i do want to point out, if you look over at those charts, you see the rate of opiod sales, overdose deaths and treatment between 1989 --
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1999-2010. the green is treatment admissions, the red are deaths, and the blue are sales. and as you can see, they're all going up in this country, i they's a good chart that really discusses what we're about. the other quick point is that heroin abuse increases as access to prescription painkillers decrease. now that's a brand new thing for me, and that's what this other chart shows. so i would hope that some of you in your testimony would remark on this. and now i would like to recognize the distinguished vice chairman who you certainly can -- >> i would like to defer to senator -- >> put on your microphone. >> i would like to defer to senator mcconnell and thank him for his interest in this issue. >> and i thank you as well, sir. thank you. >> thank you, senator feinstein, senator grassley, for the
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opportunity to be here today to testify on the scourge of heroin abuse that is devastating as senator feinstein indicated, too many families and children across america, particularly in my home state of kentucky. it will be many places in america, but it happens to be in northern kentucky. in northern kentucky area of suburban cincinnati is the center of culture arts and american history. it's the home to the cincinnati northern kentucky international airport, and the gateway to the bluegrass state from the north. residents of the three counties up there, kenton, boon and campbell, the area we referred to as northern kentucky. live in a time of great
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opportunity. they have the benefit of living in a major metropolitan area of more than 2 million people, with all the liveability and charm of a small town. they can take advantage of the cultural amenities like the cincinnati zoo and botanical gardens. they can take in a cincinnati reds game or a cincinnati bengals nfl game, or the cincinnati art museum. and over 25,000 acres of parkland give free reign to relaxation and -- northern kentucky offers all of that, and yet this proud community is also settled with the terrible distinction of being the very epicenter, the very epicenter of heroin addiction in kentucky and in the nation. they believe that the problem started because of prescription
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pain pill abuse, as senator feinstein was pointing out, kentucky has the third highest drug overdose mentality in our country. these pain pills are expensive, they cost between $60 and $100. compared to a bag of heroin at just $10 a bag. i discussed a relationship between prescription painkiller abuse and the growing heroin threat with leading agencies responsible for curbing these threats, as we all work together to fight this epidemic, i want to highlight for the drug caucus some hard but true facts about
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the extent of heroin abuse in northern kentucky and i would like to credit the northern kentucky chamber of commerce for the data. the fact that these numbers come from the chamber of commerce and not a law enforcement or public health agency demonstrates how pervasive the threat to the community is. these in 2012, heroin overdose deaths in the three county -- more than 75%. 75% in 2012, while the number of heroin overdose cases by just august of 2013 had already doubled the number in all of 2012. rates of accuse hepatitis c infections in northern kentucky are double the state wide rate and 24 times the national rate. 24 times.
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the national rate. public health officials attribute the region's high infection rate to the region's high level of heroin use. what's more, the northern kentucky health reported that for every one death, there's one new case of hepatitis c that incurs a lifetime cost of $64,500. the smallest among us are not spared from the scourge. sadly, newborn babies are born with drug withdrawal syndrome. each case is heartbreaking and not only costly in human terms but fiscally as well, incurring an average hospital cost of $14,257. law enforcement is on the front lines of this battle to protect kentucky families. according to the northern kentucky drug strike force, the number of court cases for heroin possession and trafficking has increased by 500% from 2008 to 2012. in the three counties i mentioned, and is expected to
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double again in 2013. to put this in perspective, the three counties of northern kentucky area contained 60% of my state's heroin prosecutions in 2011 even though they are home to less than 10% of the state's population. let me add here that it's fitting you are holding this hearing during national police week. when thousands of police officers from across the country visit the nation's capital. we owe these officers our profound thanks and gratitude for risking their lives to combat the drug problem. and the many ancillary violent and property crimes driven by the growing trend. clearly, the troubling facts i've just related show northern kentucky has a serious, serious heroin abuse problem. it's a major problem not for a few, but for the entire region. and while northern kentucky may be ground zero in my state, the problem of heroin abuse is spreading like a cancer across the bluegrass state where we're
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losing close to 100 fellow kentuckians a month. a month to drug related deaths. we only have 4 million people in the whole state. this is more lives loss than fatal car crashes. this march, i held a 90-minute listening session in that area of our state to hear from those closest to the problem how federal resources could best be devoted to fixing it. as i've said in boone county, one of the three counties i referred to, there are great heroes in this tragic story such as the medical professionals who save lives, the business leaders who raise money for prevention and awareness efforts, the prosecutors and dedicated investigators who take drugs off the streets, and the recovered addicts themselves who find the courage to live despite their addiction. i heard from informed kentuckians in the medical, public health and law enforcement fields and in the business community. and in particular, i want to point out one brave young man
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patrick kenyan who had been ensnared by heroin and saw his friends use it and overdosed. it took repeated attempts for him to break his addiction. but he said proudly in the listening session, he was four years and ten months clean. i can't stress enough how helpful it was to hear about this issue from so many thoughtful perspectives. that's why i'm pleased you are holding this hearing today. let me just report briefly three takeaways from the listening session i held several months ago. first is noted, it's clear that the increase in heroin addiction is tied to our fight against prescription drug abuse which is largely driven by the abuse of prescription painkillers. second, while kentucky is making progress with greater education and more aggressive prosecutions and enhanced regulatory authority at the state level, we need a combination of both treatment and incarceration to be part of the solution.
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lastly, the heroin trade is no respecter of borders, which is why multijurisdictional and multiagency law enforcement efforts, such as in my state, the appalachian high intensity drug trafficking area are so crucial. in this area of finite federal resources, we must use these inner agency partnerships to the best extent to maximize our return from federal dollars we spend to combat the epidemic. my friend, executive director, of appalachian hida never fails to remind his law enforcement partners that there's no limit to what we can accomplish when no one cares who gets the credit. the very same credo must also guide our efforts at the federal level. so senator feinstein, senator grassley, let me return to the picture i painted of a northern kentucky ripe with promise and yet beset, beset by heroin abuse. thankfully, the ending to the story has yet to be written. that's why i'm here today to share with you the gravity of the heroin threat to my constituents and to pledge work
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with all the stake holders to save lives in kentucky from this terrible growing threat. with the efficient leveraging of federal resources and authorities using best practices learned from both the law enforcement and correction agencies as well as the medical and public health communities, we can and will eliminate the shadow of this terrible heroin epidemic from robust. communities all across america like northern kentucky. thank you very much. >> thank you very much, senator mcconnell. senator grassley, you haven't made your statement and then senator klobuchar would also like to make an opening statement. >> i think since you described the situation very well, i'm going to start out at the middle of my statement and refer to something that you and i learned about the existence of a database by doctors maintained by purdue pharmaceuticals. purdue markets oxycontin, one of the most abused prescription
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opiates. the database allegedly contained information about doctors who engaged in reckless prescribing practices. during my investigation revealed many state medical boards as well as the center for medicare and medicaid services didn't know about this database. we encourage these organizations as well as dea to contact purdue about it. as a result, the information is now in the hands of authorities who could take action against irresponsible doctors. the purpose of this hearing is to learn more about what else is being done to combat this epidemic and what role congress can make. a multifacetted approach makes common sense. prevention effort through which doctors and the public are educated about the dangerousness of opioids and other addictive drugs should be a part of that solution. this is why the mixed signals,
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the obama administration sends to young people about marijuana use are also damaging. young people and all those looking to climb up the ladder of opportunity in america don't need another pathway to addiction. but that is what i think that -- what the president has said provides by failing to enforce federal laws and dismiss marijuana use as just another bad habit. treatment for those who have become addicted is also a part of the solution, as well. a drug called moloxone has shown effectiveness in countererring the effects of heroin overdoses. of course, we can't arrest our way out of this crisis, but we can and must maintain the current law enforcement tools to go after those who are trafficking heroin into our nation and our communities. unfortunately, sentencing reform bills that are now before
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congress does just the opposite. the proposed smarter sentencing act proposed out of the judiciary cuts the minimum sentencing for those who manufacture, import and distribute heroin and do that by cutting them in half. these are penalties for dealers, not for users. in the midst of an epidemic, my opinion, this makes no sense. federal prosecutors themselves wrote that the current system of penalties is a cornerstone of their ability to, quote, infiltrate and dismantle large scale drug trafficking organizations and to make violent armed career criminals to get them off the street, end of quote. i don't want to remove this cornerstone, at least of all at this particular time. thank the witnesses for being here and i'm going to put my entire statement in the record in place of what i just said. >> please do, and thank you very
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much, senator grassley. senator klobuchar. >> first, i'd like to thank you, senator feinstein and also senator grassley for holding this important hearing, for inviting me to participate. just yesterday afternoon, i was with president clinton at johns hopkins where the clinton health matters initiative held a very important forum on this very topic with the focus on prescription drug addiction and some discussion about heroin. i was on a panel with commissioner hamberg and the former representative patrick kennedy that followed president clinton's speech. and he is really taking this issue on, which i thought was a positive. and he has a lot of energy, as you know. i'd say -- i start with prescription drugs because when i look at the facts on heroin, the fact that while the vast majority of prescription drug users do not start to use heroin, something like 97% of them, in fact, 4 out of 5 heroin users today started with prescription drugs.
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so i start with the demand issue with the prescription drugs and how we get to that. and i'd say, first of all, we have to do everything we can to reduce the supply. this means to me the drug takeback programs and getting them out of the hands of kids when it's the number two thing they're addicted to. senator cornyn and i passed a bill back in 2010. seems like quite a while ago, but still waiting on the rules that makes it easier and sets out some clear standards for how these drugs can be transported when they are put into takeback programs. we did that because there's certain police departments and long-term care facilities that still are not doing these programs. and they're concerned about liability. what the bill does, it makes it easier for pharmacies, which would be excellent if they voluntarily did this. i've done some events with pharmacies, if you can imagine, people bringing back their prescription drugs, getting them out of their medicine cabinets, bringing them back voluntarily and doing it long-term care, you name it.
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so that is one thing. and if you think it's a small thing, how many tons do you think were collected just last april in one day in the united states of america prescription drugs? maybe you're thinking ten tons, 20, 390 tons of prescription drugs were collected and the day in april just this last month. and so that's what we're dealing with when we talk about the problem. second is drug courts, the more we can cut down the demand by getting people involved in drug courts and we're working on more funding for that because it's 3 out of 4 of the graduates never get in trouble again with the law. and then, the last thing i'd say on the supply side would be prescription drug monitoring. it's a patchwork system where the head of hazelton in minnesota isn't able to tell doctors when someone comes in who he knows is doctor hopping to get different prescriptions of oxycontin.
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it's patchwork, not mandatory, not interoperable, won't go across state lines and there are funding issue as well. i think that would be a big thing. so then we get to the heroin. we have had a huge increase in heroin overdoses in minnesota in the first half of 2013, 91 people died in just hennepin and ramsey county in the twin city area. why? well, we've heard the heroin is more pure, it's coming up on 35w corridor, mostly out of mexico. 50% of the heroin in the u.s. is grown in mexico now, 60% is transported through mexico. because of that and other reasons, including sex trafficking, i led a trip down to mexico last month with senator senator hicamp and cindy mccain, the wife of senator john mccain. and we focused on two issues, sex trafficking and heroin. we met with the head of the federal police in mexico, met with the attorney general. coming out of those meetings, i came back with this. i think the mexican authorities are more devoted than ever to do something about the violence and
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drugs in their country. they want to be part of this new economy in north america, they see getting rid of these drug problem and the violence is the key to that. they have gone after el chapo the head of their long time powerful drug cartel, but there's much more work to be done. this includes eradication of the new poppy fields that are pure white heroin, different than the black tar they used to be using in mexico. it includes strengthening their southern border where the heroin is coming up from countries south, not just our border but the southern border. and the third thing would be continuing coordination with u.s. law enforcement and the work that we have to do on the demand side back here. so i'm very excited you're doing this hearing as i heard the other senators talk about a major problem, but i think we have to be really smart in looking at what the answers are. and i'm looking forward to hearing from our witnesses. thank you. >> thank you very much, senator klobuchar. let me introduce our witnesses today. and we'd ask each one of you to
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confine your remarks to five minutes. and if they're in writing, we'd like to have them for the record so that we can have a robust discussion. let me begin with the acting director of the office of national drug control policy. michael botticelli has been here before and we welcome him back. he's had more than two decades of experience of of supporting americans who have been affected by substance use disorders. prior to joining, he served as director of the bureau of substance services at the massachusetts department of public health. next we welcome dr. nora volkow back to the caucus, she's the director of the national institute on drug abuse, which coincidentally founded 40 years ago today. let me be the first to wish the institute a happy birthday. dr. volkow's work has been
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instrumental in demonstrating that drug addiction is a disease of the human brain. among her many accomplishments, she pioneered the use of brain imaging to investigate the toxic effects and addictive properties for drugs -- for drugs that are abused. next, we are pleased to have dr. westly clark. he is a director of the center for substance abuse treatment within the substance abuse mental health services administration. as director, dr. clark leads the agency's nationwide effort to provide effective and accessible treatment for addiction disorders. he is a noted author and educator in the field of substance abuse, treatment and has received many awards for his service. next, we have joseph rannazzisi,
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and we are pleased to welcome you, sir, back to the caucus. you're the deputy assistant administrator of the office of diversion control at the dea. as deputy assistant administrator, mr. rannazzisi is responsible for ensuring the more than 1.5 million dea registrants comply with the controlled substances act and it's implementing regulations. he was named as deputy assistant administrator in january of '06 and served with the dea for some 25 years from now. and last but certainly not least, we're pleased to have dr. andrew kolodny. dr. kolodny is the chief medical officer of the phoenix house, one of our nation's leading nonprofit drug rehab organizations. he's an expert on our nation's opioid addiction epidemic and he's a practicing psychiatrist in the field. he's helped develop and implement multiple effective
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substance abuse treatment programs in new york and is a past recipient of the daniel x. friedman congressional health policy award. so we welcome you all and perhaps we would begin with mr. botticelli and just go right down the line. hopefully with five minutes statements so that we can then have some time for questions. please proceed. >> chairman feinstein, senator klobuchar, co-chairman grassley, thank you for the opportunity to appear here today to discuss what is perhaps the most important public health issue facing the united states. namely, the abuse of opioid drugs, including prescription painkillers and heroin. i know that given recent media attention to overdose deaths, there's a heightened public interest in the threat of opioid drug use. while this might be a new phenomena for many of our communities, some have been dealing with this issue for a
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very long time, and it's a matter of great concern for this administration. as we discussed, according to the centers for disease control and prevention, drug overdose deaths primarily driven by prescription opioids now surpass homicides and traffic crashes in the number of injury deaths in america. in 2010, the latest year of which we have nationwide data, approximately 100 americans died on average from overdose every single day. prescription analgesics were involved in almost 17,000 deaths that year and heroin was involved in another 3,000. more recent data posted by several states indicated that deaths from heroin continued to increase. while heroin use remains relatively low in the united states as compared to other drugs, there has been a troubling increase in the number of people using heroin in recent years. from 373,000 past year users in 2007 to 669,000 in 2012.
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it is clear that we can't arrest our way out of the drug problem. science has shown us that drug addiction is the disease of the brain, a disease that could be prevented, treated and from which one can recover. we know that substance abuse disorders, including those driven by opioids are a progressive disease. it's important to consider and understand that many people who develop a substance abuse disorder begin using at a very young age and often start with alcohol and tobacco. we know that as individuals' abuse becomes more frequent or chronic, that person is more inclined to purchase these drugs from dealers or obtain prescriptions from multiple doctors rather than simply getting them to friends and family for free or without asking. left untreated, this progression of an opioid use disorder may lead an individual to pursue lower cost and more potent alternatives, particularly heroin. with these circumstances in
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mind, we release the obama administration's inaugural drug control strategy in 2010 in which we set out a wide array of actions to expand public health interventions and criminal justice reforms to reduce drug use and its consequences. that strategy noted opioid overdoses as a growing national crisis and set specific goals for reducing drug use, including heroin. three years ago, the administration released the first comprehensive action plan to combat the prescription drug use epidemic. the prescription drug abuse prevention plan strikes a balance between the need to prevent diversion and abuse and the need to ensure legitimate access to prescription pain medication. the plan expands on the national drug control strategy and brings together a variety of federal, state, local and tribal partners to support, one, the expansion of state-based prescription drug monitoring programs. two, more convenient environmentally responsible disposal methods to remove expired or unneeded medication
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from the home. three, educating patients about opioid drugs and instructing health care providers in proper prescribing practices and treatment of substance use disorders. and four, reducing the prevalence of pill mills and doctor shopping through enforcement efforts. this work has been paralleled by efforts to address heroin trafficking and heroin use. the administration is also focusing on several key areas to reduce and prevent opioid overdoses, including educating the public about overdose risk and preventions and increasing access to noloxone, an emergency overdose reversal medication. because police are often the first on the scene of an overdose, the administration has strongly endorsed local law enforcement agencies to train and equip their personnel with this lifesaving drug. 22 states, plus the district of columbia, have implemented a law or developed a pilot program to allow the administration of this
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medication by a professional or layperson to reverse the effects of an opiate-related overdose. we are also working with states to promote good samaritan claws so that bystanders to an overdose will take appropriate action and help save lives. we are heartened that 17 states plus the district of columbia have now adopted good samaritan laws. while it is critical for us to save lives, we also need a comprehensive response to prevent overdose deaths. a smart public health approach requires us to catch the signs and symptoms of substance use earlier before it develops into a chronic disorder. we've been encouraging the use of screening and brief intervention to catch risky substantial abuse before it becomes an addiction. and, since only 11% of those who need substance abuse disorder treatment in 2010 actually received it, the administration is dramatically expanding access to treatment. the affordable care act and federal parity law are extending access to substance abuse disorders and mental health
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benefits for an estimated 62 million americans helping to close the treatment gap and integrate substance abuse treatment into mainstream health care. this represents the largest expansion of treatment access in a generation and will help guide millions of americans into successful recovery. the standard of care for treating substance abuse disorder is driven by heroin or prescription ownership opioids. and an approach to treating addiction that utilizes behavioral therapy along with fda approved medications. either methadone or naltrexone. medication-assisted treatment already has helped thousands of people in long-term recovery. a prime goal of our office is to increase access to medication assisted treatment within existing treatment programs and through integration with primary care. there are some signs that these national efforts are working. the number of americans 12 and older initiating the nonmedical use of prescription opioids in the past year has decreased
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significantly since 2009. additionally, according to the latest monitoring the future survey, in 2013 the rate of past year use of oxycontin and vicodin among high school seniors was at the lowest since 2002. and recent studies showed the implementation of the robust naloxone distribution programs and the ax pension of medication assisted treatment programs can reduce overdose deaths and also be cost-effective. nonetheless, the reemergence of heroin use underscore the need for leadership at all levels of government. we will therefore continue to work with our federal, state, tribal and community partners to continue to reduce and prevent the health and safety consequences of prescription opioids and heroin. thank you. >> thank you. could you just tell me, you said that heroin use has doubled. that's in the last five years? was that -- >> i believe since 2007.
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>> five years. >> i'm sorry. >> this is information from the most recent national survey on drug use and health, and it looked at people who used heroin in the past year, and that went from 373,000 past year users in 2007 to 669,000 in 2012. >> that's a very striking figure. five years. >> five years. >> very striking figure. thank you. dr. volkow, please. >> chairman and senator feinstein and senator grassley, i want to thank you for the opportunity to invite me to speak about the prescription opioid abuse in our country. opiate medications are the most effective interventions we currently have for managing acute, severe pain. unfortunately, these drugs not only inhibit pain centers but also activate brain reward regions which is why they are
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abused and why they are so addictive. so we face the unique challenge of preventing their abuse while safeguarding their value for managing severe pain which if untreated is terribly debilitating. it is estimated that 2.1 million americans are addicted to opioid painkillers, which reflects in part the widespread availability of these drugs. indeed, the number of yearly prescriptions for opioids more than doubled over the past 20 years from 76 million to 207 million prescriptions a year while at the same time in parallel there was a four fold increase in overdose deaths from these medications during that time period. painkillers like oxycontin and vicodin affect the brain similarly to heroin. they can use euphoria which some intensify by taking stronger
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doses, snorting, or injecting them or combining them with alcohol which makes them more addictive and also much more dangerous because it increases the risk of respiratory depression which is the main cause of death from opioid overdoses. recent trends also indicate a significant rise in heroin abuse in our country which currently affects more than 500,000 americans and is driven in part, basically the predominantly the new cases, by individuals switching from prescription opioids to heroin because it is cheaper and easier to access. what are we doing about the problem? it relates to three things. safe management and better management of pain, prevention of overdose deaths, and the treatment of opioid addiction. how we treat pain better and how we protect those from becoming addicted and dieing from
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overdoses. we don't know enough about the risk of addiction among people that have chronic pain. so there's basic research on that area. but in parallel, we're developing medications to treat pain effectively that are not addictive. at the same time, we're funding research to develop ways of administering opioids that minimize the diversion and abuse. and finally, we're funding research for nonmedication strategies to help manage pain such as magnetic or electrical brain stimulation. what about preventing overdoses? we have a very effective medication that is actually quite safe, naloxone, that prevents that from overdoses. recently, the fda approved self-injecting naloxone. nida is funding other user-friendly ways of administering naloxone.
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such as if the patient themselves can use it. also, since many of the overdoses occur when no one is around or the patient is asleep. nida is supporting the development of self-activated systems that initiate an emergency response when it's signaled that on overdose is occurring. finally research related to the treatment of opioid addiction. medication assisted therapies, methadone, naltrexone are all effective and they are effective in decreasing overdoses, but these medications are used in less than one-third of patients who need them. we are working to overcome the barriers that interfere with their adoption and we are doing research for alternative treatments such as vaccines against heroin addiction. we work closely with our partners, in implementing interventions towards preventing and treatment of this problem. i want to thank you again for organizing this meeting and for inviting us to participate. >> thank you very much, doctor. dr. clark? >> good afternoon, chairman
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feinstein and senator klobuchar and senator grassley. i want to thank you for inviting the substance abuse and mental health services administration to participate in this panel. i echo the comments of my colleagues regarding the importance of the topics of this hearing. i will focus on samhsa's programs and activities though we work with federal partners, states, tribes, and local communities. according to the national survey on drug use and health, which we conduct, 4.9 million people reported nonmedical use of pain relievers in the past month in 2012. 335,000 reported past month use of heroin, a figure that has more than doubled in six years.
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in 2012, more than 1.89 million people reported initiating nonmedical use of pain relievers, and 156,000 reported initial use of heroin. one challenge in combating the misuse of pain relievers is educating the public in the dangers of sharing medication. according to the national survey, 54% of those who obtained pain relievers for nonmedical use in the past year received them from a friend or relative for free. another 14.9% either bought them or took them from a friend or relative. thus we have both a public health problem intertwined with the cultural problem. we have several programs focused on educating the public, including the not worth the risk even if it's legal campaign, which encourages parents to talk to their teens about preventing prescription drug abuse, our prevention of prescription abuse in the workplace effort, supports programs for employers, employees, and their families. our partnership for success grant includes prescription drug abuse prevention as one of the capacity building in communities
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of high need. our referral to treatment program includes screening for illicit drugs, including heroin and other opioids. we've helped physicians maintain a balance between providing appropriate pain management and minimizing the risk of pain medication misuse. our screening brief intervention referral to treatment medical residency program includes modules for prescription opioids for pain management and opioid misuse. over 6,000 medical residents and over 13, 700 nonresidents have been trained nationally. our physician clinical support system for medication assisted treatment training is available via live in person, live online and recorded modules accessible at any time. we fund the clinical support system for opioid therapies, a collaborative project led by the american academy of addiction in psychiatry with six other leading medical societies. we will be funding a clinical support system on the
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appropriate use of opioids in the treatment of pain and opioid related addiction this fiscal year. at the end of april, in an article in the new england journal of medicine, describes the underutilization of vital medications and addiction treatment services and discusses ongoing efforts by major public health agencies to encourage their use. medication assisted treatment includes three strategies, therapy which uses methadone, partial which uses buprenorphine and antagonist therapy. we are responsible for overseeing the regulatory compliance of certified opioid treatment programs which use methadone and/or buprenorphine for the treatment of addiction and are being encouraged to use naltrexone. we estimate there are approximately 300,000 people receiving methadone maintenance. there are currently 26,000 physicians with a waiver to
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prescribe -- >> can i stop you. 300,000 people receiving what did you say? >> methadone. >> methadone. and that's throughout the united states? >> that's throughout the united states. there are currently 26,000 physicians with a waiver to prescribe buprenorphine. 7700 are authorized to prescribe 100 patients. we estimate there are 1.2 million people receiving buprenorphine. we also issued an advisory encouraging drug courts to utilize vivitrol in their treatment programs. we estimate between 7,000 and 10,000 people are on vivitrol and, unfortunately a low number because it's useful for alcohol dependence and opioid dependence. in august of 2013 we published the opioid overdose tool kit to educate individual, families, and first responders about steps to take to prevent and treat opioid overdose including the use of naloxone. when administered quickly and effectively, it restores breathing to a
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victim in the throes of opioid overdose. it can be a teachable moment to refer a person to the appropriate resources. we inform states and jurisdictions that the substance abuse bloc grant may be utilized to support overdose prevention education and training. in addition, we notify jurisdiction that is block grants other than their primary prevention set aside funds may be used to purchase the drug and the necessary materials to assemble overdose kits and cover the costs associated with the dissemination of such kits. we continue to focus on the mission of reducing the impact of substance abuse. and meant at illness in america's communities. we thank you and the members of this caucus for convening this important hearing and providing us with the opportunity to address this very critical issue. >> thank you very much. before mr. rannazzisi speaks i was just astonished at a statistic i just found, and this is for the most recent take back day. nationally there were 6,000 collection sites. 390 tons of medication was
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picked up. that's 780,000-plus pounds. it's amazing. >> it's amazing in the fact that we brought all these federal, state and local law enforcement agencies together with community groups on one saturday for four hours to pick up that much. and it was a collaborative effort. 6,000 sites. all that are stocked with police officers, local, state, county officers, as well as community groups, pharmacists, whoever would like to come out and work with law enforcement. so it was truly a collaborative effort. a wonderful, wonderful day. >> thank you. please proceed. >> thank you. chairman feinstein, distinguished members, on behalf of dea and the men and women of the dea, thank you for the opportunity discuss today the relationship between prescription opioids and heroin and how the dea is addressing
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this public health problem. first, let me say the present state of affairs is not a surprise. dea is concerned about the connection between rising prescription opioid diversion and abuse and rising heroin trafficking and abuse for several years. we believe increased heroin use is driven by many factors, including increase in misuse and abuse of precipitation opioids. the signs have been there for some time now. law enforcement agencies across the country have been reporting an increase in heroin use by teens and young adults who begin the cycle of abuse with prescription opioids. treatment providers report opioid addicted individuals switched to prescription opioids and heroin depending on price and availability. non-medical prescription opioid use particularly by teens and young adults can easily lead to heroin use. heroin traffickers know all of this and are relocating to where prescription drug abuse is on the rise. to give you an example, young adults can get prescription opioids for free from the medicine cabinet or their
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friends. let's assume a teenager gets hydrocodone, a schedule three prescription opioid and also the most prescribed drug in the united states today from a family medicine cabinet for a friend. once that free source runs out, it can cost as little as $5 to $7 per tablet on the street, but then the teen will eventually need more opioid to get the same effect, so increase the dose or move to a stronger opioid. thus, the cycle begins. black market sales of prescription drugs are typically five to ten times their retail value. on the street, a schedule two prescription opioid can cost $40 to $80 a tablet depending on the relative strength of the drug. it makes it difficult to continue purchasing especially for teens and young adults who don't have a steady source of income. given the high cost to maintain the prescription drug abuse habit, the teenager turns to heroin at a street cost of generally $10 a bag. the teenager gets a high similar to the one he got when he abused the prescription drugs. it's just that easy. any long-term solution must include actions to address
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prescription drug diversion and misuse while educating the public about the dangers of nonmedical use of pharmaceuticals. educating prescribers and pharmacists in treating those individuals who have moved from misuse to abuse and addiction. dea currently has 66 operational tactical diversion squads in 41 states, the district of columbia, and puerto rico. these groups capitalize on task force officers and dea agents, to conduct criminal investigations and diversion of pharmaceutical drugs. dea regulates more than 1.5 million registrants. dea diversion groups concentrate on the regulatory aspects of enforcing the controlled substances acts with increased compliance inspections. this oversight enabled dea to proactively educate registrants and ensure that dea registrants understand and comply with the law. the diversion groups have brought their skills to bear on what was previously known as
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ground zero for prescription drug abuse. florida based internet pharmacies and pain clinics, as the pill mill threat is driven out of florida and moves to the north and northwest, dea will continue to target the threat with groups proven law enforcement skills, and diversion groups, regulatory expertise, and by educating registrants. dea and law enforcement partners have aggressively targeted both prescription drug diversion and heroin trafficking. from 2001 to 2012, there was a staggering increase in opioid pain medications. a 275% increase for oxycodone, 197% increase for hydrocodone, and a 334% increase for morphine. there's also been a significant increase -- >> would you repeat that once again? >> these are coming from our national forensic lab information data. from 2001 to 2012, we saw an increase of hydrocodone to the extent of 197%. a 275% increase in analysis of oxycodone.
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>> of what does analysis mean? >> when a drug -- >> increase? >> when a drug is submitted for analysis, it's either seized pursuant to arrest, purchased undercover. what it shows is our cases are moving from the standard drug cases over to -- an increase in cases related to prescription drugs. these analyses occur across the country. if an undercover agent or undercover officer at local county sheriff's department makes a purchase undercover of oxycodone, he submits that for analysis. we get those reports. >> so what is it, tripled? is that the figure? >> 275% in an 11-year period. >> almost. so what do you deduce from that? >> i deduce we have a major prescription drug problem. >> yeah. >> it's just getting worse. heroin is just a symptom of
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prescription drug problems. >> what you're also deducing is that the prescription drug is a gateway drug to heroin, because if it gets too expensive, then the young person turns to heroin, which is much cheaper. >> i would absolutely agree with that. >> yeah. >> there was an increase in our heroin cases from 2008 to 2012. about 35%. if the data for 2013 remains constant, the increase will be about 51% for 2013. we're still getting reports in. the increase in heroin abuse and trafficking is a symptom of our country's insatiable appetite for prescription opioids that can ultimately lead to abuse and addiction. it's a natural progression from the abuse of prescription opioids. there's a dangerous misperception that abusing prescription drugs is safer than abusing heroin, but the abuse of both opioids and heroin can lead to addiction and death. preventing the availability of pharmaceutical controlled substances to nonmedical users, pharmacists, and the public about diversion trafficking and
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abuse are priorities at the dea. as such, we'll continue to work and cooperate with the federal, state and local officials, our law enforcement partners, professional organizations, and community groups to address this epidemic. thank you for your invitation to appear today and i look forward to any questions you may have. >> thank you very much. dr. kolodny? >> chairman feinstein, senator whitehouse, and senator klobuchar, thank you for the opportunity to discuss our nation's opioid epidemic. the increasing use of heroin in suburban and rural counties across the country is easily explained. if you speak with a new heroin user, they will tell you that they began using heroin after becoming addicted to opioid painkillers. this phenomenon is not new. people have been switching from painkillers to heroin since the epidemic began 18 years ago. like heroin, opioid painkillers are made from opium, and the
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effects they produce in the brain are indistinguishable from heroin. what this means is that when we talk about opioid painkillers, we are essentially talking about heroin pills. that said, these are also important medications for end-of-life care and when used to treat pain on a short-term basis. but these noncontroversial uses, cancer care or short-term use for acute pain, account for a small portion of our overall consumption. the cdc has been perfectly clear about the cause of this crisis. the chart with the three lines rising behind you is a cdc chart. the rising green line representing opioid consumption, according to the cdc, is pulling
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up the red line, which represents deaths, and the blue line which represents addiction. please keep in mind that the red line represents the loss of 125,000 lives. what this graph represents is a public health disaster of catastrophic proportion. according to the cdc, increased prescribing of opioids has led to parallel increases in addiction and overdose deaths. in other words, this epidemic was caused by the medical community. we didn't do this out of malicious intent. for most of us it was a desire to treat pain more compassionately that led to overprescribing. we were responding to a campaign that encouraged long-term use. the risks were minimized, especially the risk of addiction, and benefits were exaggerated. in fact, most patients with chronic pain on long-term opioids are not doing well.
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we are probably harming far more chronic pain patients than we're helping when we put them on long-term opioids. to help bring this crisis under control, the cdc is calling for reduced prescribing, especially for chronic pain. unfortunately, the fda has not been listening to the cdc. fda continues to approve dangerous new opioids, even over the objection of its own scientific advisers. and fda continues to allow marketing of opioids for common problems like low back pain, where risks are likely to outweigh the benefits of use. with only 5% of the world's population, we now consume 84% of the world's oxycodone and 99% of the hydrocodone supply. on what basis is fda concluding that we need more opioids? to end this epidemic, the two
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things we must accomplish are the same two things we would need to do for any disease epidemic. one, we must prevent people from developing the disease in the first place, and two, we must see that people who have the disease are able to access effective treatment. to prevent people from getting this disease in the first place, the medical community, including dentists, must prescribe more cautiously so that we don't directly addict our patients and so that we don't indirectly cause addiction by stocking medicine chests with a hazard. for the millions of americans now struggling with addiction, we have effective treatments that will allow them to lead fully productive lives. unfortunately, in communities hit hardest by the epidemic, treatment capacity does not come close to meeting demand. especially for buprenorphine treatment, where strict limits of who can prescribe and patient caps prevent many from accessing a treatment that could save -- >> explain what you mean by
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patient caps. >> well, the law data of 2000, which is the law that makes prescribing possible out of offices, limits doctors to treating 30 patients in their first year. after they have a year of experience, they're limited to treating only 100 patients. whereas a doctor who wants to treat low back pain with oxycontin can prescribe to hundreds -- as many patients as they'd like, no limits. and buprenorphine i should as is a much safer medication than oxycontin, much lower risk of overdose. if we don't rapidly expand access to treatment, the outlook is grim. overdose deaths will remain at historically high levels. heroin will continue flooding into our neighborhoods. and our families and communities will continue to suffer the tragic consequences. thank you. >> well, thank you very much. we've just been joined by
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senator udall of new mexico. candidly, as i listened, i am really struck -- you know, 30 years ago i was mayor of a big city and, we had our share, nothing like today. nothing like today. i think this testimony is amazing in terms of the tripling of heroin users, the enormous abuse of oxycontin and oxycodone and hydrocodone. the question is, you mentioned the fda just keeps on licensing regardless. i think that's something that i am going to look into. i have this question. i was the senate sponsor of the ryan haight act which went into effect in 2008 and that provided that no controlled substance
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that's a prescription drug as determined under federal food, drug, and cosmetic act may be delivered, distributed or dispensed by means of the internet without a valid prescription. and then it describes what it takes to do a valid prescription. i thought that would cut down on some of the use, which ryan haight, and his mother called me from san diego, was an 18-year-old who essentially overdosed on it and died, bought it over the internet. has that been controlled do you think by these -- by this restriction, that you have to have a prescription? >> well, evidence would -- maybe that was effective. because internet purchase of schedule two opioids doesn't seem to be a big problem right now. >> really? >> these opioids are coming from doctors who are prescribing them. >> wow. >> vicodin can be phoned in very easily, prescribed with multiple
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refills because it's in the wrong schedule right now. but for other opioids, it does require a doctor's visit. >> well, let me -- i'm -- so we solved that problem. so now we have the problem of doctors overprescribing. what would you recommend? >> well, for doctors to prescribe more cautiously, they need accurate information about the risks and benefits of these medications. what caused this epidemic in the first place, but caused the prescribing to just take off, was a very well-funded campaign with quite a bit of misinformation. doctors were taught -- i was taught that you shouldn't worry about getting patients addicted, that the compassionate way to prescribe is aggressively. and there isn't that much being done to correct the record. >> anybody else on this point? mr. botticelli and then we'll go right down the line. >> i would absolutely agree that part of what we have to look at and all of our colleagues talked about the vast overprescribing of prescription medication by
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physicians. that part of the efforts that the federal government has been doing in conjunction with nida and samhsa is providing online training courses for physicians to look at appropriate and safe opioid prescribing. we think there's more to be done in this area and we think promoting mandatory prescriber education as many states have done is really part of providing and ensuring that physicians are getting accurate information other than information that's been provided in terms of the pain prescribing patterns. you know, we keep pointing to the data and it's very, very clear that this is driven by well-meaning physicians in many cases who don't understand the lethality of these drugs, the addictive properties and are not trained in terms of looking at alternatives and how do we monitor people who might be developing an addiction. >> anybody else on this? dr. volkow? go ahead. >> in addition to the issue of education which is crucial and that overall there is missing education on the screening and
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proper prescription and management of pain in medical schools and pharmacy schools, there's also what you're mentioning, improving the access and friendliness of the prescription monitoring programs so that physicians when faced with a patient can access that information not just in their states but in other states, and i think the third issue we need to address is the fact that we have also a serious problem of severe pain of -- numbers of people with severe pain and we do not have adequate treatments to address pain for patients. it's another reality we need to face. >> thank you. dr. clark. >> we also have with the advent of the affordable care act, we have an opportunity to offer alternatives to pain medication for the treatment of pain, and i think that's something we should also keep in mind, that historically one of the problems was that there were few alternatives to pain medication for pain management because physical therapy was not available to a lot of people who suffered from pain depending on the community in which you live
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and other strategies could not be supported if the insurance companies chose not to support them. so pain medications themselves were actually relatively inexpensive despite some of the new formulations, and so with the aca having an opportunity to get nonprescription strategies to address pain becomes more available. >> thank you. dr. rannazzisi. >> just pre-ryan haight we had a massive problem with schedules 3s and 4s coming off the internet. we had one case -- well, average pharmacy in 2006 was dispensing about 66,000 hydrocodone tablets a year. that's not that much. in one case we had 34 internet facilitation sites, 34 brick and mortar pharmacies that dispensed over 98 million hydrocodone tablets. what ryan haight did was shut that down, but what did we see overnight? these were not physicians, they were traffickers.
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they gave up their white coat for trafficking and money. what we saw is overnight they moved from internet trafficking to pain clinic trafficking. we went from four to seven clinics in broward county in 2006 to over 142 in 2010. that doesn't make any sense. >> so what the you're saying, that the pain clinic is part of the problem. >> the rogue pain clinic, true, the rogue pain clinic is definitely part of the problem. these are doctors that are not practicing medicine. these rogue clinics, these are doctors that are just dispensing due to patient directed -- >> i thought that had been abated in that i think in florida, a big one was shut down. is that right? >> we decreased the number in florida through a collaborative effort between law enforcement, federal, state, and local law enforcement. they just moved into georgia. now they're up in tennessee. there's over 300 clinics operating in tennessee right
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now. georgia has over 1 -- almost 200 clinics operating right now. they're moving north and west, and these are just prescription pain mills. >> so what can we do? >> we need to get aggressive -- it's a two-prong approach. we need to aggressively attack these clinics and get them out of business as soon as possible, but the regulatory boards in the states need to take control. a lot of these clinics could have been shut down if the regulatory boards would have exercised their authority. some states don't give them enough authority. >> i'm way over my time. so senator grassley, thank you. >> my first question would be to mr. rannazzisi, and it comes from news reports that we've had about the countless deaths linked to a mixture of heroin and the painkiller fentanyl.
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in philadelphia just this week it said at least 28 people have died from the mixture. so it gives you a chance to educate us and the public. take the opportunity to tell the public what dea knows about the dangers associated with the mixture and explain why drug dealers might mix and tell us what steps dea can take to locate its sources and arrest traffickers. >> well, first of all, a little bit about fentanyl. it's a synthetic opioid. it's totally synthetic. it's not manufactured from the plant. it's manufactured in a lab. we've seen this over the years, over the past 35 years we've seen clusters of deaths related to clandestinely produced fentanyl. what we see is most of the fentanyl is clandestinely produced. most recently in 2005 or 2006 we had a rash of fentanyl deaths that were related to a lab that we tracked back into mexico to toluca, mexico, and working with the mexican authorities we closed that lab down.
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fentanyl rears its head pretty much every few years. now, this particular drug, it could be fentanyl or it could be an analog of fentanyl. it could be another analog that we're just not familiar with. but the reason they use it is because it's approximately -- fentanyl i think is approximately 100 times more potent than morphine on a standard dose. so what -- if they have bad heroin or heroin is not potent enough or if they don't have heroin, they will use the fentanyl and sell it as heroin. people don't realize how potent fentanyl is. people don't realize how difficult it is to cut fentanyl. it's measured in micrograms, so the fact is if you don't know how to cut it, people are going to be getting hot shots and die of overdoses. so it's very important that we find the labs. we have specific clandestine lab groups as well as heroin groups out there looking for the source
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just like we did in toluca. once we find the source, we'll take care of it. >> dr. volkow, common sense tells us that efforts to prevent all kinds of addictive behavior should begin as early as possible in life. i'm concerned about the increase in use of marijuana among young people leading to other addictions. you are obviously an authority on drug abuse and addiction and you have been outspoken in your views about marijuana itself being addictive. are you concerned that marijuana use by young people elevates their risk for other addictions later in life such as abusing prescription painkillers or heroin and what does science tell us about this? >> well, epidemiological studies tell us that most people that are addicted to drugs started by consuming marijuana and many of them started also by consuming tobacco and alcohol. so this leads to the concept of the gateway theory of addiction
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and what we know is exposure to marijuana-like substances in animals early on during the period of adolescence or even younger increases the sensitivity to the addictiveness of other drugs, and in studies they have shown that when the twin that starts before age 17 has a greater use of marry fwha before age of 17 has a risk of becoming addicted to a wide variety of drugs than the other twin that started after that period of time. that is important because it controls for vieftal factors that are very important to drivers of using and experimenting with drugs. so the does data does subject the use of marijuana could have an affect of making that person more vulnerable to the addict e addictiveness of other drugs.
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>> you referenced in your testimony about the administration's prescription drug prevention plan. that goes back to april 2011. the plan focused on prescription opioids. one of the goals was to reduce deaths associated with the drugs. do you think the plan needs to be revised in light of alarming developments over last three years? if so, how? or are the solutions to this epidemic a question of do dg a b better job of implementing it. >> we have to look at the emerging effort. any strategy worth its salt has to acknowledge the changing times and really look at how our trat gi continues to evolve to address the issues. as we have talked about today, the prescription drug abuse prevention plan falls in area of how we attack in a multifaceted way the issues.
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we will continue to update our strategy to talk about the evolving heroin issue. we have been continually promoting the use of medication-assisted treatment, expansion of access to treatment, particularly in primary care settings and the more widespread use of overdose prevention tools. we will evolve our strategies to reflect the changing demographic and changing use patterns and changing strategies that we need to address it. >> also, my last question in writing, i appreciate your answer. >> thank you, senator. we will do early bird. >> thank you very much, senator feinstein. i wanted to follow up, senator feinstein asked some question g questi about the drug take back question. you know have i the bill that we passed four years to make it easier to do drug takebacks. she talked about the 390 tons.
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our problem is we don't have the rules. i have talked to the director leonard three or four times. she's from minnesota. i like her a lot. i know you are working on this. i know we got them back from omb. when do you think the rules will be done? we can't support these drug take back programs to the extent that we want if we don't have the rules from the dea when it has taken four years. >> thank you for that question. thank you for your support and your leadership on that bill. that was very important for us. right now, there's just -- there's one issue that we're trying to address. >> long-term care facilities. or something like that. you don't have to tell me. i don't know what it is. >> there's one issue we're trying to address. the fact is is that omb has done their job. they vetted it through. came back to us. we're trying to work it out. >> i just know i would -- given what the senator said about the importance of that 390 tons, we could multiply that over if we
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could make it easier to have these drug take backs on a weekly basis or have them on a daily basis in pharmacies so people can bring them back. >> the problem with this bill in particular was this bill and these regulations touch on several -- >> transportation and -- >> but transportation, epa, even the military. and so we have to be very cautio cautious, because we don't have to have them go back and make serious corrections in their statutes. >> i understand. you also brought up about synthetic drugs -- thank you for bringing up that issue which is contributing to the addictions. the fact that people can manufacture them from compounds. we, of course -- senator feinstein was helpful until this and supported moving on the synthetic drugs. she and i have two different bills that are both supporting each other's bills about
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synthetic drugs with analogs and things like that. do you think that would be helpful to make it easier to prove up the cases? >> i believe any help we could get at this moment in time is going to be beneficial. we have about 200 compounds we have identified that are outside the act, non-controlled drugs representing every class of drug of abuse out there including pcp. >> thank you for what you are doing. as you know, the fda just approved maloxin, quicker than usual to be used in emergency situations. my state this month passed a bill allowing first responders to use it. i'm going to move on, because i'm obsessed with this prescription drug monitoring issue. i wanted to thank you for raising it. it's a very important -- it was the number one thing that president clinton talked about yesterday in baltimore.
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it's a very big deal. thank you. prescription drug monitoring. this is this idea that as we see all of this -- the clinics that shouldn't prescribe -- i had never heard the numbers. what did you say about the increase in the number of prescriptions, the number you used? >> more than double over 20 years. >> more than double. >> 7 million prescriptions per year. >> without that much change in our population. i don't know what -- so it's no way that all -- senator whitehouse is saying i guess this many more people are in pain. i think we know that's not the case. people are being preprescribed drugs that shouldn't be. tell me how you think if this prescription drug monitoring where at least we can put a check on these could help? >> when you say that, 390 tons --
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>> that's the drug take back. >> what it tells us why are we ending up with so many medications. >> that's a good question. >> it speaks for itself. >> that gets to the root of it. the take back is good. i want to get it done. i'm not naive to think that's going to fix our problem. it's going to help. it's going to get it out and help with kids, especially that are grabbing it from their parents' medicine cabinet. what can we do. >> we need to prescription better and we need to treat pain better. we have the technology, the prescription monitoring program should work. if i can order from google and get things immediately, why can't we not have a system like that that is interoperational that i can have one information from one state to the other. >> very quickly and then i'm out of time. >> these are complimentary strategies. when they misuse the drugs, they get them from the cabinet. they often turn to doctor shopping to do this.
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a large part of our drug abuse strategy is getting every state to have an operational and effective prescription drug monitoring program. we have 48 now that are operation operational, one in the process and one state unfortunately that refuses to invest in a prescription drug monitoring program. a big part of our work with the office of national coordinator has been easier to use programs as well as interoperable programs. they said they need to communicate across state lines. we have 20 states that have interoperable -- >> i know, senator udall has a question. they are teasing me for going way behind my time. >> that's all right. we have all been known to go beyond our time. i'm a relaxed chair.
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senator whitehouse, you are -- >> welcome. this is a terrific panel. i thank chairman feinstein and our ranking member for pulling us together. this is a very, very important topic. 38 rhode islanders died of overdoses in the first six weeks of this year. if you expand that to the population of the country into a full year, that's 100,000 americans dead per year. it's really very serious. good steps have been taken. the state police have just issue ed and recommended local police departments as well as first responders have it available. i think we're responding in good ways. one that worries me a little bit is something that's been raised a bunch here, that's these prescription drug monitoring programs. i fought for years with your agency, dea, to try to get
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scheduled narcotics on to electronic prescribing. and after -- it wasn't just you. years of bureaucratic battle, finally the regulations came out. i think that facilitates via electronic prescribing prescription drug monitoring, when you no longer have to go and ask for the paper scripts from individual doctors or from individual pharmacies, you can look at a database and you can see, this fellow is a podiatrist. why are they prescribing ochl yie ky co-don't. now they are prescribing 5,000. wait a minute. this person has gone to five doctors in five pharmacies for the same prescription. what's going on? it opens investigatory doors. and yet, years later, it's now electronic prescribing for all this stuff.
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the prescription drug monitoring programs don't seem to have yet really come online as a proper investigative tool to give us the common sense information that we need to make these determinations. what are the best next steps that we should be pursuing to try to get this program to a place where we're getting these warnings before we have to go and run up a fake pain clinic that sold 100,000 prescriptions? you shy be able to catch that sooner if you are watching the data as it comes up. what's our -- what are our best next steps? you talked about this very well. >> well, i would say that we should put the resources that are necessary to make the systems the way they should be. immediate information right away and access to data that is relevant.
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there's no reason tech technologically that we can't do it. >> privacy concerns? >> equivalent to electronic medical records. >> the data is there. we're just not accessing it in an intelligent fashion? >> correct. >> it's working with onc and with rhode island, promulgated electronic health record integration programs have got small portfolio. we work with the department of justice which has the lion's share or the primary focus. but we have been working with rhode island to improve access to data for healthcare providers by integrating rhode island's functions into electronic software used by hospital and physician office and by integrating the functions in the pharmacy dispensing software of of a pharmacy and sharing data with other states, including two geographically bordering states,
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this has to be to make this effective with new technology you don't necessarily get greater efficiency unless you iron out the bugs. we're working with rhode island health department to address this so we can establish models that we can share. >> i think mike fine, director of health, is probably the best person in the country on this. thank you for nodding your head. i'm glad to hear rhode island get some cheers here. let me wrap up by thanking -- phoenix house has an important role in rhode island. to urge that as we -- particularly as dea does the enforcement, let's not throw the baby out with the bath water. let's remember that these drugs have a purpose to alleviate human suffering. my particular concern is that when you have people who are weak and not particularly good advocates for themselves, particularly elderly people, in
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nursing homes, if they run into an episode of severe pain and you have ratcheted it down so tight that you need to wake up a doctor at 2:00 in the morning to prescribe them their medication, in the real world, they will suffer for hours until somebody can be found to come in. i hope that you will be balanced and thoughtful and precise in the way we go about pursuing this and not risk the beneficial affects of these drugs in the pursuit of eradicating their abuse. >> may i respond briefly? i believe the clinics and the practitioners that we investigate and prosecute are not doing any type of medical care. you would not want an elderly person, let alone a healthy person go to them. what we see are drug seekers go to them. they're facilitating addiction. >> i don't defend the pain clinics for one second.
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that's a racket out there. if you have a situation where you need a doctor to prescribe somebody at 2:00 in the morning and you got to wake somebody, that's a problem. a legitimate nursing home that has been there for years, you need to think of differently than a pain mill that got stood up six weeks ago. >> thank you, senator. senator udall. >> thank you, senator feinstein. good to be here with you. >> good to have sglu let me thank you for folk using on a tremendously important issue. this testimony we have seen, this chart that i think was in your package, this astronomical growth is astounding. in light of the discussion with -- i want to turn to you, doctor, and ask you on prescription drug monitoring issue, i think you wanted to say something there. so i hope that you have an opportunity to do that.
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>> i did. thank you for asking me. most states as we have heard have prescription drug monitoring programs. we can invest in interstate data sharing. unfortunately, they are not being used. they may be one of the best tools we have in country for bringing this crisis under control. and except in new york, kentucky and tennessee, the three states that made it mandatory for doctors to use them, they are just not being used. if there is some way that you can incentivize states to make it mandatory for their physicians to use them, i think that would be very helpful. >> use what? >> prescription drug monitoring. >> well, we ought to do that. that's something that we can do. >> that's what you are saying we should do, make that mandatory? >> absolutely. >> unfunded mandate. >> a worthwhile one.
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let me -- i had an opening statement, too. madam chair, i will ask to put that in the record and go on to questioning. i think such good issues have been raised here. last month in this -- last month -- i don't think you are a doctor. anyway, last month senator portman and i sent a letter signed by 14 of our colleagues to the attorney general urging the department of justice to draw on the many evidence-based strategies that are being successfully employed in states to address heroin and opiate addiction, the opiate addiction epidemic. can you explain what efforts are under way to find solutions that are working in the states? and then expand them nationwide. >> i think for starters, the states have taken a lead in having prescription drug summits, not only for the
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prescribers, pharmacists, nurses, but also for community leaders. the states have basically leveraged their community coalitions and have them out there doing education. using that as a force multiplier, we get the word out to schools. i think the states are doing a remarkable job. we're working together with an investigations related rogue pain clinics and rogue practitioners. i think that this problem, if we don't work as a team, both state and federal, local investigators and regulatory boards, it's going to get worse. we are -- we have more collaboration with regulatory boards and state and local task forces now than ever before. just to address this problem. florida is a perfect example. i think the states and the federal government together are doing a fine job.
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>> well, the great thing about our system is having the states as laboratories. they have come up with some good examples that i think we can spread nationwide. doctor, drug abuse -- i have a very large native american population, 23 tribes in new mexico. drug abuse in indian country is a significant problem. according to a survey, the rate of non-medical use of prescription drugs among american interedians was almost twice the national rate. during fiscal years 2006 and 2009, the drug trafficking areas program provided a small amount of discretionary funding for a native american program to combat drug trafficking on tribal lands. is this something you would be willing to consider as director?
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>> sure. we have been significantly concerned in terms of substance abuse and particularly this issue on tribal lands. we have been working with the indian health service to increase capacity around medication assisted treatment. we have also actually gotten great cooperation from the indian health services in making sure that all of their prescribers are appropriately trained. we have coordination with that. we are working and we will continue to work with how we might look at dollars to focus on that population. >> thank you very much. that's a perfect, i think, collaboration between the indian health service and you to move this whole issue forward. thank you very much, madam chair. >> thank you very much, senator. appreciate it. >> thank you for inviting me. i very much appreciate it. doctor, thank you for your good work in massachusetts. thank you for your good work for the country. as you know, we have been a pioneer in massachusetts in programs that distribute
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malaxono in community to those who are likely to observe an overdose. these programs save thousands of lives. my understanding is that some physicians, first responders, community volunteers have expressed concern about being held liable for lawsuits if they administer this drug in emergency overdose situations. have you also heard these concerns? >> i have. >> if we were to eliminate those liability concern concerns, do k we could increase the number of people who are ready, willing and able to save the lives of people who overdose? >> i do. i think guaranteeing some level of immunity is a strategy that we should continue to investigate. >> i agree with you. i don't think anyone should be afraid to save the life of a family member or a loved one
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because of legal liability. i recently introduced a bill called the opiate overdose reduction act. it's a simple solution to a problem. it extends protections to people who step in to save the lives of a person who is overdosing by administering a drug and that we need a national good samaritan law so that people will step in. how many lives do you think would be saved if we had such a law? >> we know one of prime issues why people overdose and die is failure to call 911 in an emergency. clearly, signaling to people that they shouldn't be afraid to call 911 is a significant advancement in how we're going to reduce overdose deaths. >> a good samaritan law would help here? >> absolutely. >> do you agree with that. >> yes. >> and i think that's really something we can do to pass a law which does provide that can
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samaritan protection. doctor, isn't it true that for opiate addicts in prison, treatment approach that works bet best is combining medication assisted therapies with community-based treatment at re-enter? >> yes, indeed we have the best outcomes on prisoners that when they leave the prison system to go into the community, were initiated on methadone and are sustained with it not just in the ability to stay off drugs but also in decreasing the number of overdoses. that transition from prison into the community increases the risk of dieing from overdose. something like 13 or 17 fold. >> there are currently very few medication assisted therapy programs in our prisons. >> unfortunately, that is correct. >> what do you think are the barriers to expansion of medication assisted therapies in federal and state prisons? >> i think that it does relate to a culture that we observe in many of the treatment programs
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that rejects the use of opiod assisted programs. they are beneficial and cost saving. >> after a life is saved from an overdose, people with chronic addiction need to be linked into effective, ongoing treatment for their conditions. i understand that you were instrumental in massachusetts in helping to increase access to medication assisted treatment programs within community health centers. do you believe this model, the massachusetts model can be used to expand access to these therapies across the country in. >> i do. you know, one of our challenges is how do we continue to expand access without building bricks and mortar. they are in rural airs to look at doing that. we found by giving anybody malassistance to federally qualified health centers, we could increase by 10,000 the
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number of massachusetts residents who were able to get very effective treatment with the rest of the services they needed. >> do you agree, doctor, that expansion of medication assisted therapies into primary care settingings such as community health settings would be helpful? >> one of the things that we supported, is integrated treatment, which would include federally qualified health centers. the other thing we would support is the transition from criminal justice system back to the community using medications which buys both the addict and the community enough time so that the person can reengage in follow-up treatment. what often happens is the person uses shortly after being discharged from the penal facility and then they overdose. so if we could have checks on injectable drugs administers prior to discharge, we would
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have a month time to engage and a community health center or a substance abuse treatment plan that would be using drugs to help facilitate reentry into the community. >> thank you. may i continue? >> go ahead. >> thank you. doctor, i'm kind of surprised at how remarkable it is that we have so few medications available to treat addiction. i'm concerned that our desire to find treatments that completely eliminate drug use may keep us from finding treatments that will reduce drug use or reduce the harms associated with drug use. harms like incarceration, family instability, difficulty holding a job. what do you think is needed to further the development of treatments that reduce drug use or related harms? >> well, it's unfortunately a paradox cal situation.
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we have a tremendous impact of morbidity. science has identified several potential targets that if developed could be beneficial for the treatment. we do not have the interest from the pharmaceutical industry in developing medications for a series of republicans. one of the recommendations is how to incentivize a pharmaceutical industry in order for them to invest in the development of medications. the targets are there. you have a condition that actually is chronic. so one of the arguments that they would not be able to recover their investment is not even correct. the institute of medicine went further and identified ways that they could -- the government could incentivize pharmaceuticals without it costing a single dollar to the government. but they have not been implemented. >> if i may ask one final question of all of the
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prescription painkillers prescribed in the world of 6 billion people, 90% were prescribed in the united states, 4% of the population of the world has 90% of the prescription painkillers. what does that tell us about the united states? what does it tell us about our society? >> i think the numbers speak for themselves. i don't think they that we can argue we have more chronic pain than other countries. the numbers are telling us something very clear. we are overprescribing. while at the same time it does not negate that we not necessarily properly treating patients that suffer with chronic pain. >> i thank each of them for their tremendous service. at the end of the day, there's one thing we can do and that is pass a good samaritan law. thousand it was peoples lives would be saved because people would not be afraid to inject someone or to give them the help that they need for fear that they would be sued if something
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went awry. we know that most people would just thank god that the fear is gone. i think firefighters across the country, policemen across the country, they would be more willing to rush in and apply -- if do you it in a timely fashion, you save the life. then you need to deal afterwards with what happens to the person. do you have a bed for them? do you have the treatment for them? at least you kept them alive. then we have a responsibility subsequently. we don't have either right now. until we put both in place, i think this problem is just going to continue to escalate. thank you. >> thank you, senator. just in conclusion, three things jump to me. of course, that's the pill mill. what proportion of the problem is the pill mill? >> i think -- we always say that
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99% -- 99% plus of the practitioners that are prescribing, the doctors, are doing a great job doing what they do. but that very small percentage of doctors that have crossed the line are truly hurting a lot people. i can't give you a percentage, because i just don't know what that number is. but what i do know is if you have a rogue pain clinic in your community, you're going to see overdose increase, you're going to see the general problems that you get with any other type of open-air drug activitactivity. it is open-air drug activity. >> we talked about medical education programs preceding. should this be done through the ama, the state medical association snz any opinion on that? >> yeah. if i can answer about pill mills. it is important to recognize -- i think we have to close down pill mills.
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they account for a large number of the overdose deaths. but in terms of the overall strategy for controlling this problem, the people who go to pill mills are usually either addicted or -- already addicted or they are drug dealers or could be both. so that could you shut down all of the pill mills and it won't get at the problem of creating new people with cases of addiction. that's where doctors who mean well are more of a problem or dentists who give a teenager 30 pills when they needed one or two. it kind of takes us to the question that you are asking about medical education. if we want dentists to give one or two pills instead of 30, if we want doctors to recognize these are not good treatment for headache and low back pain, they need very good information on this. unfortunately, the bulk of the education on this topic right now is not teaching doctors that using these medicines long-term is a bad idea. the cdc put out programs like
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that, but it's a minority of what's out there. the bulk of the education is really telling doctors that if you follow certain rules when you prescribe, it will turn out rosie in the end. if you use a pdmp, if you check urine, the patient won't wind up addicted. close monitoring is aprudent thing to do for the people who are on this treatment. but it doesn't turn it into something that's safe. these strategies don't prevent addiction. the education needs to be that these are not good treatments for most people with chronic pain. >> do you think we should mandate the states to mandate that medical programs, essentially to mandate physicians licensed to use drug monitoring progr ining programs? >> i think new york, tennessee and kentucky did that and use went way up. states that don't require this,
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very few doctors look at the database. a doctor thinks they know what an addict looks like. they think they know what something with this disease looks like and they don't. >> thank you very much, everybody. i think it was a very good hearing. we have some very good notes and food for thought. thank you very much. it's appreciated. the hearing is adjourned. on next washington journal, a look at the recent drop in gas prices in the u.s. our guest is nick timiraos.
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wednesday, live coverage of the funeral service for former "washington post" editor ben bradlee who died last week. once night on c-span3, the big ten series continues at the university of illinois.
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the 20 is a c-span student cam video competition is under way. open to all middle and high school students to create a five to seven minute documentary on the theme the three branchs and you. showing how a policy, law or action by the executive, legislative or judicial branch has affected you or your community. there's 200 cash prizes totals $100,000. for the list of rules and how to get started go to our look at drug abuse in the united states continues with a discussion about alter maives to jail time for people convicted of possessing illegal drugs. this hour and 15 minute event was hosted by the heritage foundation. >> thank you, john.
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thank you everyone here and everyone watching on tv or over the internet. we are pleased to present this program today. it involves some very important issues. we have some very distinguished panelists. let me say that for some time now society has been bedevilled by alcohol abuse, illicit drug use and crime. the intersection of each of those problems magnified the adverse affect of each one. but state and local officials in south dakota and hawaii have found some creative ways to try to address those problems through two very innovative programs. 24/7 sobriety and with a hawaii's opportunity with enforcement program. those programs seek to achieve three rather elusive goals in the criminal justice system. to reduce incarceration, to reduce recidivism and to reduce substance abuse.
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to reduce incarceration, the programs place offenders on probation. to reduce res sid vichl and suss stance abuse, they rigorously and frequently drug test for alcohol or other illicit substances in order to determine whether or not people have stayed sober and clean. both programs have proved very successful in achieving the goals they set out for themselves. and in the meantime, both programs have also proved very cost efficient. these creative programs deserve our careful consideration, because they are reasonable and humane ways of addressing several of the problems in our criminal justice system. and i am very fortunate to say we have three experts on these type of programs here. first to my left is the honorable larry long. judge long is a native of the mount rushmore state.


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